Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Michelle Wojciechowski, Administrator, after identifying herself and disclosing the purpose of the visit. Administrator was in the process of an online seminar for her recertification of her Administrator's certificate and was not available for the annual inspection. An overall tour of the facility was conducted by Jeffrey Wojciechowski, Staff. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed with Jeffrey Wojciechowski the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment).

Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC808. No deficiencies were observed during today's visit. An exit interview was conducted with Jeffrey Wojciechowski and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) was provided via email; Administrator expressed that they would send LPA a confirmation email upon receipt of these documents.